DESCRIPTION: The metabolic syndrome (MetS) is a collection of risk factors including abdominal obesity, hypertension, hyperlipidemia, and hyperglycemia that is a known risk factor for cardiovascular disease and diabetes. However, there is also a growing body of literature that supports the association of the MetS and neuropathy. While it is well recognized that diabetes mellitus and pre-diabetes are commonly associated with a painful sensorimotor small fiber neuropathy it is less commonly known that individuals with the MetS also suffer from a similar painful small fiber neuropathy that often involves the autonomic nervous system as well. In addition, there is early evidence that the MetS is an independent risk factor for falls (1). However, it is not known if a targeted exercise and balance training program would be successful in reducing the fall risk in this patient population. The proposed research pilot project will assess participants with evidence of the MetS and autonomic neuropathy for fall risk as measured by the Four Square Step Test (FSST), which is a valid and sensitive test of dynamic standing balance (2). Additional endpoint measures that will be evaluated for the first time in this population include the Dynamic Gait Index (DGI) performed on an instrumented gait mat (GaitRite). The participants will then be randomized to either a standard care group and received education regarding fall risk and prevention or a targeted balance exercise intervention group. [Both groups will meet once a week for a group class and the exercise intervention group] will be instructed in a home balance exercise program to perform three times a week. After a 12 week intervention period the participants will be reassessed to determine if the balance exercise intervention was successful in reducing fall risk compared to the standard care group who did not participant in the balance exercise program. In addition the participants will complete self-efficacy measures at baseline and after the intervention. The different endpoint measures will be evaluated as part of this pilot study to determine which is the most appropriate assessment tool of balance performance and fall risk in this population. This new information will be used to design future clinical trials. Te applicant, Dr. Lindsay Zilliox, is a Neurologist at the Baltimore VAMC and an Assistant Professor in the Department of Neurology at the University of Maryland who recently completed her clinical training and has a history of involvement within the VA. This 5 year CDA-2 will allow her to gain additional skills in clinical research as well as the use and interpretation of autonomc testing through ongoing mentorship with Dr. James Russell, with whom she has worked on VA funded research trials and published several peer-reviewed journal articles with. In addition she will work with a co-mentor, Dr. Mark Rogers in the Department of Physical Therapy and Rehabilitation, to complement her knowledge in the field of peripheral nerve disease with research in neuromotor control of balance and locomotion. She will not only collaborate with Dr. Rogers and his colleagues, but participate in coursework and seminars that are offered through the Graduate School of Physical Rehabilitation Science. A third mentor, Dr. Michael Terrin, will provide expertise in clinical trial methodology. This is a novel and independent research project and the experience will provide her with the necessary tools to establish herself as an independent VA researcher.